Medical Error as a Cause of Death Revisited

The relationship between medical error and patient death has been become increasingly accepted over the past 2 decades. The Institute of Medicine’s 1999 Report ‘To Err is Human’ acted as a major catalyst in the promotion of safety in the practice of clinical medicine. It calculated that 44,000 – 98,000 deaths occurred annually in the US due to medical error. At the time the results caused widespread international concern and dialogue. It was presumed that what happens in US hospitals also occurs in other countries. Some groups were initially slow to accept the findings and conclusions of the Report. Greater clarity has emerged over time. It is now universally agreed that clinical errors occur but their frequency continues to be debated. One of the problems is that ICD-10 coding system has only a few codes where the role of error or a preventable factor can be communicated.

Makaray and Daniel’s recent study1 has rekindled the argument. They state that error is the third commonest cause of death, the leading two being diseases of the heart and malignancies. They maintain that 251,454 deaths in 2013 were caused by error. The numbers dying from heart disease was 611,105 and that for cancer was 548,881. They derived their data by formulating an estimate from 4 studies, 2000 – 2011. The worrying feature of their paper is that their quoted number of deaths is more than twice that reported in the IOM report. Some commentators have challenged the estimates stating that the study did not use any formal methods of systematic review or meta-analysis. However, it is appreciated that the higher the actual number the greater the priority the issue of safety will receive. Berwick, a renown expert on patient safety, has stated that debating the precise numbers is not that important. The key issue should be the institution of safe practices. The basic promise in medicine is do no harm and we must ensure that this happens. The challenge is that the delivery of high quality safe care is more time consuming, more expensive, and requires higher standards of clinical care. It has taken time for health services and hospitals to factor in these additional costs. The first big step was to introduce a culture of safety in all hospitals and healthcare systems. The mantra ‘best care first time and every time’ is commonly quoted. There are some encouraging signs that things have improved. There has been a decrease in adverse drug events, catheter associated urinary tract infections, central line infections, pressure sores, and surgical site infections2. Misdiagnosis has not improved to the same degree because it is difficult to measure and difficult to prevent.

The causative factors in an error are communication breakdown, misdiagnosis, poor judgment, and inadequate skill. Medical mistakes are a cause of distress for medical staff. However they do happen, and staff must know how to confront them. It must be recognized that the delivery of complex care such as ICU and specialist surgery is associated with an increased potential for error. Sixty years ago ICUs scarcely existed.

An open reporting system is important if repeat adverse events are to be avoided. The main obstacle to honest debate about error is the excessive emphasis on blame. Clinicians are understandably fearful of medicolegal actions and regulatory bodies. Ascribing blame to one individual is convenient and easy but too simplistic. The examination of the systematic background of an error is more time-consuming and expensive. However, the adoption of the latter approach is pivotal if we are to aspire to better error prevention governance. It is recommended that a distinction be made between unprofessional conduct and human mistakes. Human limitations must be taken into account. Healthcare workers should not be punished for genuine mistakes, otherwise individuals will not report them. If error is not recorded measures cannot be adopted to prevent it happening again. The introduction of meaningful safety metrics depends on good reporting systems.

The ways of reducing error include making them more visible, having a strategy to manage them, and taking human limitations into account when designing clinical services. Most units have found post weekend take meetings a safe, informal environment to discuss what went well and what could have done better. If an error has taken place it is important to deal with it at the first opportunity. The patient’s welfare must be the priority and everything done to redress any resultant complications. Patients can understand that errors occur but they find it hard to accept when the adverse event is not revealed or explained to them.

The human factors in the delivery of care needs a better understanding in order to put prevention measures in place. Strict adherence to hand washing and prevention of cross infection must be practiced by all healthcare workers at all times. Surgical and procedure timeouts represent confirmation of the patient’s identity, surgical site and planned procedure. Electronic prescribing has the potential to reduce drug errors. Electronic patient record systems can help to ensure that important laboratory and radiological investigation results are not misplaced or overlooked. Integrated care programmes help to reduce the fragmentation of services which is a common source of error. Competency based training of junior doctors improves clinical efficacy and patient safety. It ensures that the doctor can deal with a specific clinical situation in an effective safe manner. Electronically available algorithms and guidelines help the physician to manage a case in a methodical, timely fashion. Good communication with the patient and his family is of paramount importance. The patient plays an important part in his diagnosis and correct management. His inclusion in all aspects of his care is mutually beneficial for both the patient and the physician.

Finally there needs to be greater understanding of the risk-benefit ratio of procedures and/or medication before they are administered to patients.

JFA Murphy

Editor

Makary MA, Daniel M. Medical error – the third leading cause of death in the US. BMJ 2016;353